Provider Demographics
NPI:1083144752
Name:MARTIN, MELISSA (RN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 W GROVE ST STE 120
Mailing Address - Street 2:
Mailing Address - City:KAUFMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75142-1883
Mailing Address - Country:US
Mailing Address - Phone:972-932-1319
Mailing Address - Fax:
Practice Address - Street 1:1011 W GROVE ST STE 120
Practice Address - Street 2:
Practice Address - City:KAUFMAN
Practice Address - State:TX
Practice Address - Zip Code:75142-1883
Practice Address - Country:US
Practice Address - Phone:972-932-1319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX661834163WP0200X, 363LP0200X
TXAP134351363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics